Patient Biographical Information    
Patients 18 and Over
 
*First Name:  
  Middle Initial:
*Last Name:  
  Nickname:
*Birthdate:    
*Gender:  
 Marital Status:
*Address:  
*City:  
*State:  
*Zip:  
*This form is being completed by:
*If other:
*Main Phone:  
*Cell Phone:  
*Email:  
 Employer:
*Occupation:  
 Work Phone:
Patient's interest in treatment:
   
What is the patients main orthodontic concern?
Please list the names of any friends or family currently in the practice:
Whom may we thank for referring you to our practice?
 
  Dental History     
 
Dentist Name:
Address:
City:
State:
Zip:
Has the patient had an orthodontic consultant or treatment?
If so, when?
Check-up Frequency:
Last Dental Visit:  
 
*Please answer the following questions. (Cannot be left blank.)
  Speech problems/therapy?
  Grind or clench teeth?
  Oral habits (thumb/finger sucking, nail biting)?
  Injury to face, jaw, teeth or mouth?
  Discomfort from teeth or gums?
  Pain, tenderness or noise in either jaw?
  Frequent headaches?
  Neck/shoulder pain?
  Frequent sore throats?
  Excessive bleeding following extractions?
  Trouble associated with previous dental work?
  Brush teeth daily?
  Floss teeth daily?
  Fluoride treatments?
  Mouth breathing?
  Snores during sleep?
  Requires premedication?
  Any missing or extra permanent teeth?
  Apprehensive about dental care?
  Frequently chew gum?
  Periodontal/gum treatment?
  TMJ/jaw joint treatment?
 
Please provide necessary explanations below:
       
   Medical History     
 
Physician Name:
Address:
City:
State:
Zip:
Date of last Physical:  
Patient Health:
 
*Please select YES if the patient has had any of the conditions listed below either now or in the past.
  Rheumatic Fever
  Tuberculosis/Lung Disease
  Pneumonia
  Liver Disease
  Kidney Disease
  Heart Attack/Stroke
  Heart Disease
  Congenital Heart Defect
  Heart Murmur
  Hemophilia
  Hypertension/High Blood Pressure
  Prolonged Bleeding/Transfusion
  Anemia
  HIV/AIDS
  Hepatitis
  Tonsils/Adenoids Removed
  (Women) Are you pregnant?
  If pregnant, please give due date
  Cancer
  Family History of Cancer
  Received Radiation Treatment
  Growth Problems
  Endocrine Problems
  Hormone Therapy
  Latex/Metal Allergy
  Nervous Disorders
  Bone Disorders/Bone Loss
  Diabetes
  Seizures/Epilepsy
  Handicaps/Disabilities
  Asthma
  Arthritis
  Treated for Emotional Problems
  Ever Been Hospitalized
  Do you use tobacco in any form?
If use tobacco, how much?
If any of the above medical questions were answered 'Yes' , please explain:
Is patient currently under the care of a physician? Please explain:
Are you currently or have you ever taken any bisphosphonate medications for the treatment of bone loss? (ie. Actonel, Boniva, Phosomax, Reclast, etc.) If YES, please explain:
List any other medications currently being taken by the patient:
List any drug allergies or sensitivities that the patient may have:
 
  Spouse's Information    
 
First Name:
Middle Initial:
Last Name:
Address:
City:
State:
Zip:
Main Phone:
Cell Phone:
Email:
Employer:
Occupation:
Work Phone:
   
Who will be financially responsible for the treatment?
   
  Financial Party Information    
 
 
*First Name:  
Middle Initial:
*Last Name:  
*Address:  
*City:  
*State:  
*Zip:  
*Main Phone:  
*Cell Phone:  
*Email:  
 
Relationship to Patient:
If other:
Employer:
*Occupation:  
Work Phone:
   
Would you like us to provide you with insurance forms?